Provider Demographics
NPI:1134495377
Name:FREDERIKSEN, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:FREDERIKSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 BEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:ANDREWS AIR FORCE BASE
Mailing Address - State:MD
Mailing Address - Zip Code:20762-5410
Mailing Address - Country:US
Mailing Address - Phone:702-370-6277
Mailing Address - Fax:
Practice Address - Street 1:1012 14TH ST NW
Practice Address - Street 2:SUITE 1000
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20005-3406
Practice Address - Country:US
Practice Address - Phone:202-737-2554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-31
Last Update Date:2012-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500794171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical